Form Approved
OMB Number: 0920-1092
Expiration Date:09/30/2025
Review the death and the death investigation
Review factors surrounding the death event
Discuss and understand the child’s health, family history and social history
Identify risk factors present in the death
Identify whether a previously undiagnosed heart condition or other medical condition was present that could result in sudden death.
Identify whether previous symptoms at rest or during exercise associated with sudden death wereknown.
Identify whether the child had a family history that put him/her at-risk for sudden death.
Evaluate whether changes are needed to the agencies and/or systems that were involved with the childand/or responded to the death
Identify whether a previously undiagnosed heart condition or other medical condition was presentthat could result in sudden death.
Identify whether previous symptoms at rest or during exercise associated with sudden death wereknown.
Identify whether the child had a family history that put him/her at-risk for sudden death.
Identify and develop recommendations for primary and secondary prevention of SDY
Public Reporting of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA, 30033; ATTN: PRA (0920-1092).
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |